2.0 Analysis 2.1 Stability As a small fishing vessel of closed construction built before July 1977 and not engaged in catching herring or capelin, the CapRougeII was not required to comply with the stability-related requirements of the Small Fishing Vessel Inspection Regulations and meet the minimum intact stability criteria of STAB4 of the Stability, Subdivision and Load Line Standards (TP7301). However, irrespective of the particular mode of fishing in which a small fishing vessel is engaged, these criteria are generally regarded as the most appropriate yardstick against which their transverse intact stability characteristics may be assessed. When considering the stability of a small fishing vessel, the STAB 4 minimum criteria ensures that these small vessels attain adequate margins of intact transverse stability throughout a range of loading conditions related to the vessel's intended service. The criteria do not ensure immunity against capsize, regardless of the circumstances, and are dependent on the watertight integrity of the hull, weather deck hatches, and other deck openings. Since its construction in 1974, the stability characteristics of the CapRougeII have been subject to change due to the installation of various combinations of equipment to suit different fishing modes. From 1987, when it was employed as a herring packer with the seine net and drum removed, until the time of the capsize, her stability characteristics were steadily reduced as more, heavier gear and seine nets were installed. The effects of these increases in weight were not monitored or assessed by a suitably qualified person, nor brought to the attention of Transport Canada (TC) inspectors between or during routine quadrennial inspections. Section 24.71(2) of the Workers' Compensation Board of British Columbia (WCB) Occupational Health and Safety Regulation (OHS) calls on owners to ensure that major modifications to their fishing vessels do not adversely affect stability, but gives no direction with regard to acceptable minimum stability criteria. In this instance, a larger seine net was being employed, the weight of which was not verified until after the capsize, when it was found to be some 7.4tonnes. This weight was somewhat heavier than the seine net usually carried, which weighed approximately 4.5tonnes. The nets were routinely stowed on the power drum, located 1.75m (5.67ft) above the main deck, where their weight effectively raised the position of the vessel's centre of gravity. After the capsize, the quantity of diesel recovered from the vessel was recorded and showed that the tanks in the engine room and lazarette were all partially full. The skipper was under the impression that the engine room tanks were full. Subsequent stability analysis shows that, had both engine room tanks been full, there would have been a slight improvement in stability, but insufficient to counter the detrimental effects caused by the remaining free surface effects and other weights in the vessel. At the beginning of the return voyage, the forward fish holds were reportedly about 2/3 to 3/4 full and the after holds approximately 1/8full. The freshwater tank was also in use and about 1/2 full. Consequently, at the time of the capsize, the relatively lightly loaded vessel was subject to detrimental effects due to free surfaces in five storage tanks, four hold compartments and the lazarette, in addition to water shipped and retained on deck. In general, few fishers fully understand free surface effect, and fewer appreciate the substantial reduction of initial transverse stability that results when water, even a few centimetres (inches) deep, is shipped and retained on deck. When this occurs on a vessel with inherently low stability characteristics and is coupled with a significant loss of waterplane area when the deck edge becomes immersed, the sudden reduction in transverse stability can be catastrophic. Upon recovery, the vessel's rudder was found to be positioned approximately 20 to starboard. However, all available information indicates that there was no alteration of course to starboard immediately prior to the capsize. The 20 rudder angle is consistent with an autopilot reaction to a deviation from a preset course brought about by any uneven forces acting on the vessel. The hydrodynamic rudder forces generated by such a rudder reaction, applied below the vertical centre of gravity of the heeled hull, would create a slight heeling moment to starboard in addition to the upsetting effects already acting on the vessel. In addition to one such voyage in 2001, this was the second voyage made in 2002 with the heavier seine net on board. No untoward concerns were raised during the earlier voyages, however the seine skiff was not towed extensively on these occasions. Fully-loaded voyages with some 30000kg (66000lbs) of fish onboard and the original lighter weight seine net stowed on the drum were also successfully completed. However, further analysis of this fully-loaded condition shows that, while somewhat less than the minimum criteria of STAB4, the fully- loaded, intact stability characteristics were significantly greater than when lightly loaded, as at the time of the capsize. The unexpected and rapid heel to starboard and the inability to recover are typical of behaviour associated with the presence of extensive free surface effects acting in conjunction with inherently low transverse stability. The dynamic impact of any minor heeling moment in the prevailing confused sea conditions would, in the later stages of such heeling action, be sufficient to overcome any residual righting ability retained by the vessel. Such a scenario is consistent with the sequence of events reported by the survivors on board the CapRougeII. 2.2 Ship Inspection and Safety The CapRougeII had undergone modifications since 1987 which adversely affected her stability. Although three quadrennial inspections were carried out following the 1987 modifications, TC reportedly became aware of these modifications only after this occurrence. These inspections are intended to ensure that vessels proceeding to sea are in a seaworthy condition. Therefore, good inspection practice ought to consider all aspects of seaworthiness when visiting a vessel for inspection. Following the disappearance and presumed sinking of the small fishing vessel Le Bout de Ligne in 1990, the Transportation Safety Board of Canada (TSB) issued two recommendations. The Board recommended that TC emphasize, through a safety awareness program for owners, operators, and officers of fishing vessels, the adverse effects of structural modifications and additional items on vessel stability (TSB RecommendationM94-31, issued December 1994). As well, the Board recommended that a means be created to ensure that structural modifications and the addition of weight items are recorded and accounted for in reassessing the stability of small fishing vessels (TSB RecommendationM94-32, issued in December1994). In response to TSB Recommendation M94-31, TC issued a Ship Safety Bulletin (16/96) to remind operators of fishing vessels to have their vessels inspected following modifications. However, it did not have wide circulation. Also, the Small Fishing Vessel Safety Manual (TP10038) was re-issued in 1993 and again in March2003. The manual, which contains information about the many things that can affect the stability of a vessel and cause it to capsize, was distributed to Prairie and Northern Region and in Ontario using the provincial licensing database. For other regions, TC is awaiting a distribution list from the Department of Fisheries and Oceans (DFO) fishing license database. The manual, presented in simplified format, is also available free of charge at TC offices and on the TC website. In response to TSB RecommendationM94-32, TC agreed with the recommendation but reiterated that the onus is upon the owners to report any alteration of the hull, machinery, or equipment affecting compliance with Regulations. While TC noted that it is the responsibility of the owner or master of the vessel to notify them of any alteration, there is a requirement which states: any alterations made to the vessel since the previous inspection shall be reported in detail by the inspector to the Chairman.17 Although this requirement is found in paragraph38(4)(h) of the Large Fishing Vessel Inspection Regulations, it does not apply to small fishing vessels such as the CapRougeII. The principle, in the interest of safety, should equally apply to all vessels inspected by TC. Consequently, it should be incumbent upon the inspector to be vigilant and to inquire of the master or owner if any alteration has been carried out between inspections. The requirements for reporting alterations are being formally addressed by TC in the proposed Fishing Vessel Safety Regulations. In the meantime, inspectors are being instructed to seek this information when carrying out inspections. 2.3 Operational Practices and Awareness of Risks The TSB has observed that many crews on fishing vessels do not fully appreciate that some of their day-to-day operating procedures may create unsafe conditions. A number of practices were observed that carried risks which were either not fully recognized or were accepted by the skipper. For example, the skipper considered the CapRougeII to be a wet boat', indicating that it was not unusual to see water on deck or to have to pump out the lazarette. Water accumulating on the main deck and also downflooding contributes to a free surface effect and thus adversely affects the stability of the vessel. Operation of the vessel with the holds partially filled indicates that, like most commercial fishers, the skipper did not fully understand the risks associated with free surface effect. A vessel's capability to remain safely upright requires its operator to have a sound understanding of the principles of ship stability and to apply them in a manner which takes into account the constantly changing circumstances both on board a vessel and in the surrounding environment. For example, it is necessary to monitor changes in the quantity and location of liquids held in fish hold tanks, fuel tanks, freshwater tanks and oil tanks. It is also necessary to decide on the safest manner of stowing fish product and fishing gear, including nets, to assess the configuration of standing rigging, such as a boom, and to determine the safest manner of transporting a skiff. Knowledge of existing external factors such as sea state, wind characteristics, and under-keel salinity is also extremely important. TC has recognized the importance for fishing vessels operators to understand the theory and practice of ship stability. Applicants seeking certification for either Class1, 2, or 3 Fishing Master are examined in this knowledge. However, this requirement is not extended to Class4 Fishing Master certification, even though knowledge of stability is of equal importance to these operators.18 TC requires a Class 4 Fishing Master applicant to pass an oral examination on matters of general seamanship, which includes ship stability. The examiner is required to assess the candidate's ability to use and interpret stability and trim data supplied to fishing vessels and to assess other aspects of stability in general terms and excluding calculations or by demonstrating a practical appreciation. Currently, many small fishing vessels are not provided with specific stability information and, if it is provided, it is not presented in a manner that is readily understood by fishers. As only basic knowledge is required, an awareness of what constitutes a dangerous situation is left to personal interpretation based upon the operator's own experience and the experience of others. Considering the number of accidents and incidents involving small fishing vessels, the required knowledge of vessel stability should not be relaxed for this level of certification. In this accident, the hinged door in the after end of the deckhouse was secured in the open position. The opening permitted the ingress of water into the deckhouse when the vessel heeled sufficiently to starboard. Consequently, significant reserve intact buoyancy, contributing to the vessel's righting ability, was lost (see section 2.1 Stability). Closure of weathertight openings, such as deckhouse and accommodation doors, when operating at sea is important to prevent water from entering the vessel and for the safety of all persons on board. The TSB has conducted several investigations into marine accidents involving small fishing vessels in which the failure to maintain weathertight integrity has been identified as a causal factor.19 Following the sinking of the small fishing vessel Pacific Bandit in 1995, the Board issued a recommendation to TC, in conjunction with other agencies, to undertake a safety promotion program to increase awareness among operators and crews of small fishing vessels of the effect of unsafe operating practices on vessel stability (TSB Recommendation M96-13, issued December 1996). Although the Minister agreed with the recommendation, actions taken since 1996 have been limited to the formation of working groups to study the issue and to issuing a Ship Safety Bulletin(12/2000) to warn operators of how changes in operational loading conditions may adversely affect vessel stability. In May 2001, a standing committee on fishing vessels was formed to review safety issues pertaining to the small fishing vessel industry. The intent of TSB Recommendation M96-13 was to encourage an immediate safety awareness campaign among those who are in the best position to correct unsafe operational practices. The actions taken have focussed on the review of proposed Regulations for dealing with small fishing vessel safety. The effectiveness of ship safety bulletins in raising awareness within the small fishing vessel industry is compromised by their limited distribution. A review of the Ship Safety Bulletin mailing list in 2001 revealed that there were no west coast fishing associations listed. However, in March 2003, TC responded to this safety concern from another occurrence20, stating that in partnership with DFO, TC, and stakeholders, discussions were underway with respect to the possibility of distributing safety-related material, such as Ship Safety Bulletins, using the DFO database of fishing vessel licence holders. Additional information provided by TC states that registered owners will be added to the Ship Safety Bulletin mailing list. It is noted that TC, the Canadian Marine Advisory Council Standing Committee on Fishing Vessel Safety and its various working groups have undertaken important work toward the development of the new Fishing Vessel Safety Regulations, the intent of which is to address many of the recurring safety deficiencies. The WCB also inspects fishing vessels in accordance with provincial workplace standards for health and safety and consults with vessel owners, operators, and crews to promote health and safety. The WCB recognizes that commercial fishing is one of the most dangerous occupations in British Columbia and has produced, in co-operation with the Joint Fishing Industry Safety and Health Committee, a manual to address common safety and health hazards in the industry. Gearing Up For SafetySafe Work Practices for Commercial Fishing in British Columbia is meant to complement TC's Small Fishing Vessel Safety Manual. The WCB has produced other publications as well as safety-related videos. The WCB also issues hazard alerts to provide important safety messages to workers. One hazard alert, for example, about fish harvesting, was issued in 2002. The alert illustrated the types of fatal accidents which occurred on fish harvesting vessels from 1991 to 2001. It also summarized the correct safety procedures for owners, masters, and crew members of fishing vessels to follow. Although safety-related information is distributed by the WCB directly to fishing associations, processors, and other industry interests, such as insurance companies, unions, and native groups, few are sent directly to fishers. Safety information is available on the WCB's web site but it is doubtful that this type of venue is being used by the majority of fishers as a source for safety-related information. Accidents involving fishing vessels continue to account for approximately half of all shipping accidents in Canadian waters. TSB statistics show that in 1993, 368 Canadian fishing vessels were involved in shipping accidents, while 231 such accidents occurred in 2002. It should be noted that the number of fishing vessels has markedly declined over the years, however, the number involved in accidents remains proportionally the same. Despite current efforts to affect change, unsafe operating practices continue, placing vessels and crews at risk. 2.4 Adequacy of Arrangements for Escape from Small Fishing Vessels In emergency situations, crews may be required to use alternate escape routes and means of escape to exit wheelhouses and deckhouses. Consequently, alternative escape routes and means of escape should not only be located in a manner which prevents one incident blocking all escapes, but also be adequate in their design to facilitate ease of escape. There were three means of egress from the combined wheelhouse and deckhouse of the CapRougeII. A hinged door on the starboard side of the wheelhouse provided egress to one side of the forecastle deck. A combined hinged top hatch and door at the after end of the wheelhouse on the vessel's centreline led to the deckhouse top (see Figure 1). A hinged door in the after end of the deckhouse to starboard of the vessel centreline provided egress to the open after deck. There was no means for escape from the port side of the superstructure and none of the port side wheelhouse windows was fitted for use as an emergency exit. Given that the CapRougeII heeled to starboard as it capsized, the escape would have been increasingly difficult to access as water entered the vessel. With a means of egress on the port side, those inside the vessel would have had an alternative means of escape. The benefit of having at least two clearly separated means of escape from crew spaces has been recognized by TC21. However, when the vessel was built, Regulations did not require a second means of escape. Furthermore, small fishing vessels constructed after 1988 are not required to have a second means of escape where, in the opinion of an inspector, a second means of escape is not practicable due to size limitations or spatial layout of the crew space or area in which the crew may be normally employed22. The TSB is not aware of any established procedures or guidelines to assist inspectors in determining whether the fitting of a second means of escape is not practicable nor are there guidelines to help inspectors to determine the most appropriate second means of escape. Although the TSB database shows that there have been few occurrences in which the limitations of the means of escape were found to be contributing or causal factors, it is difficult to estimate the extent to which a lack of means of escape has impacted survivability of crews of small fishing vessel occurrences. The TC Vessel Registration Query System shows approximately 5500small fishing vessels currently registered in Canada, of which approximately 4100 were constructed prior to May 1988. Given the high percentage of vessels constructed prior to 1988, which may be operating without a second means of escape, and that 96 of the 100small fishing vessels reported to have capsized since 1975 were constructed prior to 1988, crews may be unnecessarily put at risk should their vessels capsize or sink. 2.5 Abandonment Drills and Procedures The situation involving the CapRougeII demonstrates that crews of small fishing vessels may have little time to assess the severity of an emergency situation and formulate a plan of action. Where a vessel is listing heavily and may be in danger of capsizing, the amount of time available for an orderly abandonment is limited. Emergency situations are inherently stressful. Individuals may selectively focus on information and not accurately assess the probability of adverse events. This could lead to an over-estimation of a positive outcome. Such a bias has the potential to delay a decision to abandon the vessel until it is too late. Training and practice serve to reduce this potential for error by providing crews with an opportunity to practice their response to emergency situations prior to an actual emergency. In this way, when faced with emergencies, crew response will be more automatic and require less interpretation and decision-making23. To have this effect, any training received must be regularly reinforced by using a combination of recurrent training and ongoing practice. As of 31 July 2002, every member of the complement of a Canadian fishing vessel is required to successfully complete training in marine emergency duties (MED) with respect to basic safety before the member has completed six months on board vessels. This three-day course provides a basic understanding of the hazards which may be encountered at sea and the knowledge necessary to deal with emergencies, including what appropriate assistance should be provided in abandonment situations. The course also covers the purpose and importance of regular drills and training. In this occurrence, one of the two survivors had received this training. The absence of emergency drills can effectively negate the benefits of emergency training to the detriment of safety. There is currently no requirement for crews of fishing vessels of 150gross registered tons (GRT) or less to carry out fire and boat drills. In November 1999, TC issued a Ship Safety Bulletin(13/1999) highlighting the importance of regular practice of emergency procedures and encouraging all vessels to do so. Furthermore, TC is considering extending the application of these requirements to fishing vessels below 150GRT. Section 24.74(2) of the BC OHS regulation for licenced fishing vessels states the master must ensure that drills are conducted at the start of each fishing season, when there is a change of crew, and at periodic intervals to ensure that crew members are familiar with emergency procedures. As federal requirements for emergency drills do not extend to vessels such as the CapRougeII, the provincial requirement is aimed at addressing this shortfall. However, there is no information confirming emergency drills were regularly carried out on board the CapRougeII. The capsizing sequence of the CapRougeII underscores the importance of emergency abandonment drills and procedures. Unless the decision to prepare for abandoning the vessel is made before the problem has become critical, the crew may not have sufficient time to leave the vessel. Emergency training and the reinforcement of such training are critical to making timely decisions with respect to abandoning a vessel. 2.6 Workload Associated with On-scene Co-ordinator and Rescue Dive Operations In this occurrence, the crew of Canadian Coast Guard (CCG) hovercraft CCGH045 carried out the responsibilities of the on-scene co-ordinator (OSC) while also conducting dive operations. No concern was expressed by the Joint Rescue Co-ordination Centre (JRCC) or the OSC during the rescue operation about the dual role and associated workload that the crew of CCGH045 performed. According to the CCG Rescue Diving Manual, a vessel conducting a dive operation is not to be involved in coordinator duties until the last diver is out of the water. Rescue dive operations are demanding, since they involve seeking and processing information and closely monitoring a continuously developing high-risk situation. Taking on the additional workload required of an OSC in certain circumstances, it may be beyond an individual's ability to handle. This could compromise the safety of both rescue dive operations and search and rescue (SAR) activities. Even with the extra officer on board, the crew on the hovercraft was fully engaged and performing tasks which demanded full attention. In addition to conducting rescue dive operations and ensuring that the hovercraft remained on station, the OSC and crew were engaged in other activitiessometimes simultaneously. In fact, the JRCC's SAR Operations Report for this accident concluded that . . . the crew was involved in dive operations meant that the [On-scene co-ordinator] became over-tasked24. Consequently, on board small CCG vessels, the workload associated with being OSC while also engaged in rescue dive operations may jeopardize the safety and effectiveness of rescue operations. 2.7 CCG Dive Policy The CCG open waters dive team was on a scene at the CapRougeII 17minutes after receipt of the distress call. A second dive team from Canadian Forces (CF)442 Squadron, capable of performing penetration dives, was also tasked to respond to the capsizing. Between CCG resources arriving on the scene and the arrival of the CF442 Squadron divers, the CCG dive team did everything possible within the scope of their procedures to reach the victims of the capsizing, including an external search of the vessel and the recovery of one victim from the wheelhouse with the aid of a boat hook. During these activities, it is reported that both divers became entangled on separate occasions but were able to free each other. The provision of rescue diving on the west coast has been the subject of numerous reviews. Few definite conclusions with respect to the need for rescue diving or the provisions of rescue dive services have ever been reached. This created a situation in which a rescue dive team was set up, largely due to the initiative of the personnel at the Sea Island base. The situation was described by Mr.Bernard in his review of the decisions surrounding rescue diving: With respect to the Rescue Diving Pilot Project, departmental policy and procedure concerning rescue diving was not created. The pilot project did not have official recognition from the National Directorate of Marine Programs and, to a great degree, it operated on an ad hoc basis from Sea Island largely due to the strong desire and dedication of those directly involved. The Rescue Diving Pilot Project was essentially a Coast Guard pilot project in name only25. A rescue dive operation, by its very nature, faces unique challenges and hazards. There is, therefore, a requirement to have a well-trained and highly professional team, capable of calculating and mitigating risk in a continuously changing risk environment, so that the level of safety is not diminished. In preparing for rescue diving, the CCG Sea Island team worked to achieve these capabilities and developed extensive expertise in the conduct of rescue diving, to the extent that the training practices developed were adopted by other rescue dive operations, including the CF 442Squadron SAR technicians. However, there were ongoing concerns regarding the training documentation for divers and the requirements of the Canada Labour Code (CLC). The Code requires a backup dive team where there is a possibility that a diver may become entrapped. In order to comply, CCG issued a blanket prohibition preventing divers from penetrating overturned vessels, aircraft, or vehicles. This policy was put in place with the intention of containing some of the risks. Under these provisions, the dive team was reinstated following the accident of 18 February 2001. This did not, however, remove potential hazards associated with diving around capsized vessels where there is a very real risk of entanglement from loose lines, netting, and other floating debris. It created a situation under which divers could: encounter a demand for dive operations, such as a penetration dive, that could not be carried out safely; and make an inaccurate determination of the potential of entrapment which could place them at risk without a backup team in place. Given the expectation of the public and the marine community to conduct dives without restriction, significant external pressures can be put upon rescue divers to conduct dives where greater risk may be accepted. Following the occurrence, statements were made which indicated that penetration dives could take place under certain conditions without backup. This created ambiguity and uncertainty within CCG as to what could or should have happened on the day of the occurrence and whether or not the CLC provisions could be suspended in the future. CCG policy was later modified to permit penetration dives without backup where it was considered necessary to save a life and the decision would be made by the appropriate SAR authorities. This created a situation where divers could be placed at risk. The issues were resolved when, on 06 February 2003, the Minister for the Department of Fisheries and Oceans made an announcement that clarified this situation in that the dive project is being expanded (see Section 4.1.1). 3.0 Conclusions 3.1 Findings as to Causes and Contributing Factors Inherent transverse stability was progressively reduced by structural additions and the installation of more and heavier fishing gear, including the adoption of a West Coast seine net of 7.4tonnes, all of which were located at or above the main deck level. The installation of additional gear and its effects on stability were not monitored or assessed by a suitably qualified person, nor brought to the attention of Transport Canada (TC) inspectors, between or during routine quadrennial inspections. The watertight integrity of the main deck was compromised by the ineffective gaskets of five flush-fitting manhole covers, which resulted in extensive downflooding, a marked increase in after trim, and reduced transverse stability. Because of their limited knowledge of basic principles of trim and stability, the additional weight of the seine net, the inherent heel to starboard, the routine presence of water on deck, and the towing resistance of the seine skiff were not considered by those on board the CapRougeII to present any undue risk to vessel operation. The vessel lost transverse stability due principally to the cumulative free surface effects of water shipped and retained on the main deck and other liquids in four partially full fish holds, four fuel tanks, a freshwater tank, and the lazarette. The rapidity of the capsizing precluded orderly abandonment of the vessel. 3.2 Findings as to Risks Current small fishing vessel inspections require only those small vessels over 15gross tons engaged in fishing for herring or capelin to submit trim and stability data for approval. Other small fishing vessels, such as CapRougeII principally employed in other fisheries, are not required to submit such data for approval, nor is there any mandatory requirement for owners of these vessels to forward this information to TC for safety review or information purposes. On board small Canadian Coast Guard (CCG) vessels, including hovercraft, the workload associated with being on-scene co-ordinator while also engaged in rescue dive operations may jeopardize the safety and effectiveness of rescue operations. Many small fishing vessels that operate without a second means of escape, or a means of escape that may not be optimally positioned, may unnecessarily put crews at risk. There are no established procedures or guidelines to assist TC inspectors in determining whether a vessel should be fitted with a second means of escape. The absence of emergency practice drills negates the benefits of emergency training. Many fishers are unaware of shipboard practices which adversely affect vessel stability and the profound risks those practices create. 3.3 Other Findings When fully loaded and fitted with an inside seine net, the vessel's transverse intact stability characteristics were somewhat lower than the minimum criteria of STAB4 of the Stability, Subdivision and Load Line Standards (TP7301). When partially loaded and fitted with a West Coast seine net, as it was at the time it capsized, the vessel's stability characteristics were substantially lower than the minimum STAB4 criteria. Between CCG resources arriving on scene and the arrival of the Canadian Forces442 Squadron divers, the CCG dive team did everything possible within the scope of their procedures to reach the victims of the capsizing. 4.0 Safety Action 4.1 Action Taken 4.1.1 Canadian Coast Guard Dive Policy On 21 January 2003, the Transportation Safety Board of Canada (TSB) sent Marine Safety Advisory (MSA)01/03 to the Commissioner of the Canadian Coast Guard (CCG), identifying areas of potential concern arising from the rescue dive operation in this occurrence. Three main issues were addressed: over-tasking of hovercraft crews who were conducting both rescue dive operations and on-scene coordinator duties; safety of rescue divers working around capsized vessels in the absence of a backup dive team; and the ability of CCG divers to provide an adequate backup to Canadian Forces (CF) search and rescue (SAR) divers, given their incompatible communication systems. Following this MSA, on 06 February 2003, the Minister for the Department of Fisheries and Oceans announced that the capabilities of the rescue dive team at the Sea Island base would be expanded to provide a dive team with a full backup 24hours a day. This would increase the complement on board the hovercraft and allow the rescue dive team to conduct penetration dives in keeping with the provisions of the Canada Labour Code. The provision of surface-supplied air would further mitigate the risks of conducting penetration dives. A specific implementation date was not identified, given the requirements to recruit and train additional rescue specialists for the role. Following the occurrence, the issues of over-tasking and penetration dives were re-examined by the department and the CCG's Fleet Safety Manual was modified as follows: These changes came into effect on 06 February 2003. Regarding concerns over communications systems, the response indicated that it is not possible to provide equipment to allow direct communications between CCG and CF divers. Both CCG divers and CF divers from the Fleet Diving Unit in Colwood use surface-supplied air and their communications are hard-wired to the surface. The CF search and rescue technicians, who use self-contained underwater breathing apparatus, are deployed from aircraft and are equipped with underwater voice communication capability between divers. While they are submerged, they are not equipped to communicate with other personnel on the surface. However, it should be noted that all divers are trained in the use of hand signals and that the Canadian Standards Association26 requires communication between diver and surface. Additionally, a memorandum of understanding between CCG and the Department of National Defence is being prepared which will include joint training and communications. 4.1.2Adequacy of Arrangements for Escape On Board Small Fishing On 18 March 2003, the TSB sent MSA 05/03 to Transport Canada (TC) to inform them of the potential deficiency associated with the lack of appropriate means of escape in crew spaces which may put the safety of persons on board small fishing vessels at risk. In response, TC indicated that work is ongoing with regard to the development of revised construction standards that will be incorporated into the proposed new Fishing Vessel Safety Regulations. As part of that process, the requirements for a second means of escape from crew spaces of small fishing vessels will be reviewed. Additionally, consideration will be given to re-writing this section such that it can be more readily enforceable. To achieve this, the owner will be required to demonstrate: that either the vessel complies with a stated prescriptive measure, or that alternative design and arrangements are consistent with a stated safety objective. 4.1.3 Near-sister Ship Stability Approval On 13 May 2003, the TSB forwarded a Marine Safety Information Letter(06/03) to TC to advise that there were two other small fishing vessels, Western Leader and Western Mist, that could be considered as near-sister ships to CapRougeII. Stability data generated from an inclining experiment conducted 18 May 1976 had been forwarded to TC for approval and was refused. A request was made for the vessel to be re-inclined. Revised data was submitted 12 May 1977 and approval was given 26May 1980 for .salmon seining only. While neither vessel was re-inclined, TC concluded that it was satisfied that the vessels' designers/naval architect had presented the necessary corrections to allow approval of the re-submitted stability data. The information was forwarded by the TSB to apprise TC of the discrepancies and the possible implications to the vessels involved. It has since been learned that the Western Leader is no longer registered in Canada and that the Western Mist is operating as a pleasure craft. Consequently, concerns regarding any reduction in transverse stability due to heavy fishing gear have been allayed. However, the TSB has informed the current owners of the stability approval history of their vessels. 4.2 Action Required 4.2.1 Stability Approval for Small Fishing Vessels There are approximately 20000 small fishing vessels in service in Canada. Of that number, 4500 are greater than 15gross registered tons(GRT) and less than 150GRT and are inspected by TC on a quadrennial basis. Because of the mode of fishing in which they are engaged, some of these vessels are currently required to comply with regulatory stability requirements. The 15 500 vessels of less than 15GRT are uninspected and are not required to meet any regulatory stability standard nor to have any basic stability data provided for the guidance of their operators. Since 1990, TSB investigations into the capsize, foundering or sinking of 47 inspected small fishing vessels of more than 15GRT, and 29uninspected vessels of less than 15GRT, have shown that these occurrences were primarily due to inadequate intact stability or stability-related unsafe working practices. The majority of the inspected vessels and all of the uninspected vessels were not required to meet any regulatory stability standard. Only those small fishing vessels engaged in fishing for herring or capelin are required to submit stability data for approval by TC. Stability data approval, in accordance with the Small Fishing Vessel Inspection Regulations, is based on exceeding the minimum criteria in STAB4 of the Stability, Subdivision and Load Line Standards (TP7301). In order for the criteria to be verified, an extensive amount of vessel design information is required, including hull hydrostatics and righting lever curves, hold and tank capacities, and centres of gravity at several levels, together with weights and locations of all fishing gear on board. Furthermore, an inclining experiment must be completed in order to determine the vessel lightship weight and centre of gravity from which a comprehensive assessment of the vessel's stability characteristics may be generated. This design information is generally available for the more recent additions to the fishing fleet, and is readily generated for new or future vessels. Many older vessels have no design data or hull form information from which hydrostatics data may be derived. Furthermore, the adoption of new fish catch storage techniques on board existing small fishing vessels calling for holds to be filled with refrigerated or chilled sea water has, in some cases, led to a significant reduction in effective freeboard, reserve buoyancy and related transverse stability. However, the adverse effects of this development on existing and new small fishing vessels are best addressed by the regulatory stability approval process ensuring that a worst loading condition incorporating a maximum load condition meets the minimum stability criteria of STAB4, and does not result in a loss of all reserve buoyancy. It is recognized that the compilation and approval of the data would enable these older vessels to demonstrate compliance with STAB4 criteria. In comparison, conducting a roll period test and a corresponding freeboard verification is a simple procedure and may be completed in port in approximately 15minutes. While a roll period test only provides an estimate of the initial transverse metacentric height(GMt) related to the loading condition of the vessel at the time of the test, it does give an indication of stability relative to other vessels of similar size and type which have given satisfactory service for some years. Any significant deviation from the normal range of GMt values will give a timely indication that an unsatisfactory transverse stability condition exists. In May 2003, TC sought to modernize stability requirements with a project based, in part, on input from the Standing Committee on Fishing Vessel Safety of the Canadian Marine Advisory Council(CMAC). Because of the ongoing loss of lives and vessels, the necessity for developing and introducing appropriate stability requirements for all small fishing vessels has been recognized. A comprehensive program has been set in motion to evaluate and assess the impact of new proposed safety standards developed from the results of stability experiments and tests conducted on a representative sampling involving some 30vessels of the small fishing vessel fleet, many of which are below 15GRT. The TC project calls for the participation of vessel operators. A primary goal is to validate more appropriate stability standards for future application to fishing vessels under 24metres in length. In-the-field data collection is to be carried out in two parts. Part1 will address small fishing vessels exceeding 15metres in overall length (such as the CapRougeII), while Part2 will focus on vessels of open construction less than 15metres in overall length. The preliminary results of these studies are expected to be reported at the CMAC meetings scheduled for November 2003 and the spring of 2004. Review and analysis of the collected data, intended to define appropriate minimum stability criteria related to various sizes of vessel and their operational characteristics, are to be completed by September 2004. Timely approval and acceptance of the proposed new criteria by TC and industry stakeholders are scheduled so that the results may be incorporated in the new Fishing Vessel Safety Regulations due for implementation in 2006. The Board is encouraged by the initiation of this project to determine and extend the application of appropriate stability standards for all small fishing vessels and notes that TC is in the process of actively addressing a major safety risk to which crews of small fishing vessels have been and continue to be exposed. Until such time as new small fishing vessel safety Regulations are introduced, the Board recommends that: The Department of Transport require all new inspected small fishing vessels of closed construction to submit stability data for approval. M03-05 Assessment/Reassessment Rating: Fully Satisfactory The Department of Transport require all existing inspected small fishing vessels currently without any approved stability data be subjected to a roll period test and a corresponding freeboard verification not later than their next scheduled quadrennial inspection. M03-06 Assessment/Reassessment Rating: Fully Satisfactory 4.2.2 Promoting Safe Practices On Board Fishing Vessels Since 1993, TSB statistics show that about 50 per cent of all vessels involved in shipping accidents have been fishing vessels. In that period, 493 Canadian fishing vessels have been lost, and 76 fishers lost their lives. In many of these occurrences, unsafe practices, which served to compromise the vessel's watertight integrity and stability, have contributed to the occurrence. These occurrences are typical of situations where the level of risk during fishing operation rises gradually over time. The capsize of the CapRougeII was brought about by such an increase in risk involving a reduction of stability due to the weight of additional equipment, deterioration of watertight seals on lazarette and manhole covers, and operation with the deck awash. Such unsafe practices are not carried out with the intention of jeopardizing the safety of the vessel and crew. Rather, they are carried out by individuals who mean to operate their vessels in a safe manner but who, for a number of reasons, do not fully appreciate the risks associated with such practices. In general, people tend to underestimate risk. In order to assess the level of risk associated with an activity, there is a need to be aware of the severity and probability of negative outcomes. Within the Canadian fishing industry for example, while some 49vessels are lost every year, on average, they represent only a small proportion of the 20000small fishing vessels in operation. As such, there is a high probability of a vessel safely completing each voyage. Each successive voyage safely completed increases the individual's perception that the probability of an accident is low. Consequently, the more comfortable the individual becomes, the more unsafe practices may be carried out, placing vessel and crew at greater risk. Therefore, efforts to eliminate unsafe practices on board small fishing vessels are required, focussing on changing fishers' attitudes toward the risks involved. Increasing an individual's motivation to adopt safe practices will best be achieved through a concerted effort to change actual behaviour in conjunction with a program to educate fishers with respect to the risks involved in their operation. In this way, the justification for adopting safe practices will change from one which is externally imposed to one stemming from internal acceptance. Previous efforts to change attitudes within other modes of transportation have relied upon such an approach. For example, consider the effectiveness over the last two decades in changing attitudes toward seat belt use and greater passenger safety. Existing efforts to promote adoption of safe practices within the fishing industry, through education and awareness programs, have shown limited success. As demonstrated in this accident, there continue to be occurrences involving fishers who, although having attended training courses, persisted in the use of unsafe practices. Therefore, formal training for fishers may not always achieve its objective of promoting practical application of classroom theory. Possible reasons for this include a lack of perceived relevance of course content or a method of delivery which does not provide sufficient application of the subject matter. It is essential that any education and awareness program which aims to promote safety employ educational techniques which are most likely to impart useful knowledge to operators so that they will make use of that knowledge and consequently reduce the risk of accidents. Adult learning principles indicate that adults learn best when learning activities reflect their individual learning style, take advantage of previous experience, relate to their everyday world, and simulate real world situations27. Since 1990, the TSB has issued a number of safety communications28 addressing deficiencies related to stability awareness, unsafe on-board working practices, structural modifications, and loss of watertight integrity. To address these deficiencies, a number of measures have been instituted which include publications, ship safety bulletins, audio visual aids, and training workshops. In spite of these efforts, accidents associated with those deficiencies continue to occur. The Board, therefore, continues to be concerned with the lack of real progress. In 2003, the Board's report (TSB Report M01L0112) of an occurrence involving the small fishing vessel Alex B. 1 stated only through a concerted and overarching effort to change the existing paradigm within the fishing industry, and specifically establish a true safety culture within it, can the risks to fishers be reduced to acceptable levels. The Board recommended that: Transport Canada, in coordination with Fisheries and Oceans Canada, fisher associations and training institutions, develop a national strategy for establishing, maintaining and promoting a safety culture within the fishing industry. (Recommendation M03-02, issued September 2003) Given that attitudes and beliefs toward risk form the basis of an effective safety culture, the Board recognizes that developing this safety culture will require a long-term effort to promote positive attitudes toward safety within the fishing community. Therefore, given that there is a need to initiate a change in attitude among fishers as demonstrated by this occurrence, and facts supporting Recommendation M03-02, the Board further recommends that: The Department of Transport, in collaboration with the fishing community, reduce unsafe practices by means of a code of best practices for small fishing vessels, including loading and stability, and that its adoption be encouraged through effective education and awareness programs. M03-07 Assessment/Reassessment Rating: Satisfactory Intent